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Comment by elhudy | Hacker News Reader

I read the article and my point still stands. Put yourself in the shoes of the patient (who largely drives their own care for these situations). You get covid, you go into the dr with a cough and say "dr, this is getting bad, and I'm obese and scared!"

The dr goes, "well, we have this drug that was proven to be slightly effective in double blind placebo controlled trials. It has no adverse side-effects. But a large scale study showed it might not actually be effective. Would you like to try that?"

The patient, who is probably on medicare or hit their deductible, is going to say yes give me that shit.

People have been saying this same thing about the over-prescription of antibiotics for ages but nothing has changed.

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> I'm obese and scared!

Might I say the unsayable with not too scared to lose weight?

Perhaps doctors should be ignoring the pride of their patients and telling them, after 3 years, to take their health seriously instead of waiting for the grim reaper to knock on their door? Doctors are also able to prescribe weight loss drugs, surgeries, and generally tell people what they really need to hear so we might ask why the problem persists. Maybe it's because they don't listen to advice they don't want to hear. From [1]:

> The researchers found that disagreement between GPs and patients increased with patients' excess weight and was particularly pronounced for advice given by GPs on weight and lifestyle issues. Overweight patients were more likely to disagree with their GP regarding advice given on weight loss (odds ratio, 10.7), advice given on doing more physical activity (odds ratio, 1.9), and nutritional advice (odds ratio, 2.9) compared with patients with a "normal" body mass index.

I'm not suggesting doctors be rude, and, as that study points out, if doctors are taking such steps and obese patients ignore them and it harms the relationship then should we not be considering other things to push them?

Some people propose sugar taxes and the like but I think that still pushes responsibility away from the main cause of the problem, which is the person. Obese people should pay higher taxes and/or insurance fees that are then mitigated by efforts such as slimming classes, gym attendance etc.

Or, we can continue to allow a section of society to risk their own health and mortality while putting enormous strain and cost on the health service and thus risking everyone's health and mortality. Arguing about a drug that most of them wouldn't need if they weren't obese seems a bit like rearranging deck chairs on the Titanic to me, even if they do need rearranging.

[1] https://www.drugs.com/news/patient-doctor-disagreements-more...

Or we disallow its use so it can’t be prescribed and instead the Dr gives them Paxlovid.

see my below response re: paxlovid and its interactions

In this case there is a much more effective drug available—-Paxlovid.

Totally agreed, however...

>There are 636 drugs known to interact with Paxlovid (nirmatrelvir/ritonavir), along with 5 disease interactions, and 2 alcohol/food interactions. Of the total drug interactions, 236 are major, 360 are moderate, and 40 are minor.

Of these interactions, several are with: statins, blood thinners, hormonal birth controls, and other heart medications. The exact high-risk population who is taking these drugs, have potential interactions with paxlovid. That wipes out a significant portion of the general population from eligibility.

636 interactions sounds impressive. But almost any drug that’s been around for a while (like Ritonavir has) will have hundreds of interactions listed.

Drug interaction databases aren’t complete nonsense, but you should take them with a huge grain of salt.

The vast majority of those interactions won’t prevent a physician from prescribing Paxlovid, and for most of the rest there are either alternatives or patients can lower dosages or stop taking them for the duration of treatment.

For better or worse, I'm fairly certain statins do prevent drs from prescribing paxlovid on occasion. Happened to a family member. Tons of high risk / older Americans are on statins.

There are statins that can be taken with Paxlovid. The general recommendations are to either to stop taking them 12 hours before through a few days after treatment or switch temporarily to one of the statins that can be take with Paxlovid.

I agree that in an ideal world, drs would recommend your course of action. I am not debating that statins can be stopped and paxlovid taken, with statins resumed after the disease has run its course. that doesnt change the fact that doctors will still hesitate to prescribe paxlovid if their patient is on statins. This could be for a number of reasons - but consider for a second that up to 55% of seniors are already noncompliant in listening to their drs and taking their medication.

When you are asking a patient to stop taking a drug that they have habitually taken for potentially decades, and they have shown hesitancy or inability to comply in the past, maybe prescribing a drug with a potentially serious interaction isnt the best course of action.

Your argument has now went from: significant portion of the population aren't eligible, to: doctors might hesitate to prescribe it to old people because old people can't follow instructions.

We were talking about a hypothetical situation where someone is scared because they high risk.

The Doctor can A--tell that person to change their medication (they don't have to stop statins, not all statins can't be taken with Paxlovid) for 2 weeks and take Paxlovid.

Or B they can take Molnupiravir, which worst case doesn't do much, and best case is much less effective than Paxlovid. Also Molnupiravir has mutagenic effects (which granted probably aren't as much of a concern for someone 65+).

Molnupiravir was approved based on early data that showed it was much more effective than it has proven to be, and at a time when Paxlovid production hadn't ramped up yet. It very likely wouldn't be approved if it were being evaluated today.

Based on it's potential to produce more variants, and it's not widely studied mutagenic effects, keeping it around because some doctors might hesitate to prescribe Paxlovid to a subset of old people seems less than ideal.

No, my argument is still that a significant portion of the population is ineligible. The anecdote above is just to help you understand a large piece of that ineligibility. If you want to understand that ineligibility yourself, feel free to take the fda checklist and add the populations within each exclusion and see how many tens of millions of people that is: https://www.fda.gov/media/158165/download

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